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ASN Wikibase Occurrence # 229427
Last updated: 22 October 2021
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Date:16-SEP-2019
Time:20:00 UTC
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different
Airbus A320-214
Owner/operator:easyJet
Registration: G-EZWE
MSN: 5289
Fatalities:Fatalities: 0 / Occupants: 173
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Lisboa-Humberto Delgado Airport (LIS/LPPT) -   Portugal
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Lisboa-Humberto Delgado Airport (LIS/LPPT)
Destination airport:Manchester International Airport (MAN/EGCC)
Investigating agency: AAIB
Narrative:
The easyJet Airbus A320, G-EZWE, arrived into Lisbon Airport, Portugal at 18:25 UTC having flown in from Manchester Airport, U.K.. The passengers were disembarked, and the crew began the process of preparing the aircraft for its return flight (U21820) to Manchester. Once the cabin preparation was complete, the passengers were released from the terminal for boarding. During pre-flight preparations both flight deck crew members were subjected to numerous interruptions. These included details of a sick passenger at the back of the aircraft, a change in fuel requirements, a mix-up over passengers released from the terminal and a late change to the loading figures. Both crew members calculated takeoff performance as required by the operatorís procedures and cross-checked their results. During this process, the crew inadvertently selected what they believed to be an intersection on runway 21 for takeoff but was in fact the full length. This error was not picked up during the initial calculation or during the pre-takeoff check of the performance.
The commander was Pilot Flying (PF) for the return flight. The aircraft pushed back from its parking position at 19:45 UTC and proceeded to taxi to the holding point for runway 21 on Taxiway U5.
The aircraft took off from Taxiway U5 at 19:59 UTC with performance calculated for the full runway length. The commander reported that the takeoff initially seemed normal but both flight crew realised there was something wrong as they saw the red and white alternate lights of the last 900 m of the runway. Takeoff/go-around (TOGA) thrust was not selected.
The takeoff distance available from U5 was 1,395 m less than that used for the performance calculation, and the aircraft became airborne with only 110 m of the runway remaining. During the flight the crew realised what had happened, and they reported it to the operator after landing.

AAIB Conclusion:
The aircraft took off using incorrect performance data for the intersection used. A selection error was made in the EFB calculation which led the crew to believe that they had calculated performance information for a departure from S1 when in fact they had selected the full length of the runway. In this case, as in the two previous identical incidents, the final barrier of checking the runway distance in the performance calculation against the aerodrome ground chart failed to prevent to error. Human performance limitations mean it is difficult for pilots to recognise and react to the performance error once the takeoff has begun, so robust adherence to procedures is a key defence against such incidents occurring.

As a result of previous incidents, but after this occurrence, the Lisbon Airport operator re-designated the taxiways on 5 December 2019.

Sources:

https://www.bea.aero/en/investigation-reports/notified-events/detail/event/incident-grave-dun-airbus-a320-exploite-par-easyjet-survenu-le-16092019-a-lisbonne-portugal-enq/

Previous incorrect performance takeoffs at Lisbon Airport:
24 April 2019, easyJet Airbus A320
7 May 2019, easyJet Airbus A320
3 Dec. 2015, Transavia Boeing 737-800

Accident investigation:
cover
  
Investigating agency: AAIB
Status: Investigation completed
Duration: 10 months
Download report: Final report


Images:

Photo of G-EZWE courtesy AirHistory.net


La Palma (GCLA / SPC)
15 February 2020; (c) Luis Rodriguez


Revision history:

Date/timeContributorUpdates
27-Sep-2019 17:28 harro Added
27-Sep-2019 17:29 harro Updated [Time, Location, Source]
27-Sep-2019 17:30 harro Updated [Source]
06-Aug-2020 18:05 harro Updated [Total occupants, Narrative, Photo, Accident report, ]
06-Aug-2020 18:49 harro Updated [Source, Accident report, ]
06-Aug-2020 18:50 harro Updated [Narrative, Accident report, ]
05-May-2021 14:48 harro Updated [Cn]

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